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State of California—Environmental Protection Agency <br /> Form Approved OMB No.2050-0039(Expires 9-30-99) See Instructions on back of a 6. Department of Toxic Substances Conh <br /> Please print or type. Form designed for use on elite(12-pitch) iter. Sacramento,California <br /> 1. Generator's US EPA ID No. Manifest Document No_ 2. Page l Informotion in the shaded areas <br /> UNIFORM HAZARDOUS is not required by Federal law. <br /> WASTE MANIFEST C L 000 , 0 1 2 3 r3 0 4 0 0 1 of 1 <br /> 3. Generator's Name and Mailing Address <br /> B t R AUTO REPAIR <br /> 6789 MAIN ST. <br /> in SAN JOSE , CA 95128 <br /> 4. Generator's Phone ( ] <br /> CgUSAnFgS <br /> CV 5. Transporter 1 Company Name 6. US EPA ID Number <br /> W <br /> Goldun Bear Transportationj qA I DI 17 18113 121 16 15 <br /> 7. Transporter 2 Company Name S. US EPA ID Number <br /> J <br /> Q <br /> U 9. Designated Facility Name and Site Address 10. US EPA ID Number <br /> ZKalifornia Environmental <br /> 111213 Septic Tank Wy <br /> �2_ Oakland <br /> "+ 12. Containers 13. Total 14. Unit <br /> 11. US DOT Description(including Proper Shipping Name,Hazard Class,and ID Number) <br /> V' No. Type Quantity Wt/Vol <br /> Oily Absorbent , Non-RCRA Hazardous <br /> 3 Waste , Solid <br /> .. F <br /> o N b. <br /> DO E , <br /> N' R <br /> St A E <br /> o T <br /> co Q <br /> R <br /> LU d, <br /> t— <br /> Z <br /> w <br /> V <br /> v1 <br /> su <br /> at <br /> �.s <br /> a <br /> Z 15. Special Handling Instructions and Additional Information <br /> Q <br /> Z <br /> 16. GENERATOR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by proper skipping name.and are classified,packed, <br /> marked,and labeled,and are in all respects in proper condition for transport by highway according to applicable international and nationol government regulations. <br /> r if I am a large quantity generator,I certify that I have a program in place to reduce the volume and toxicity of waste generated to the degree I have determined to be economically <br /> a practicable and that I have selected the Frociica6le method of treatment,storage,or disposal currently available to me which minimizes the present and future threat to human healtf <br /> and the environment;OR,if I am a small quantity generator,f have made a good faith effort to minimize my waste generation and select the best waste management method that is <br /> W avakilable to me and that I can afford. <br /> Printed/T ped Name Signature Montle Day Year <br /> z oBlN aDNe-s 01 -2-1 l1 -7101C) <br /> st l T 17. Transporter 1 Acknowledgement of Receipt of Materials <br /> C�C R - -- Month Da Year <br /> U A Printed/T ped Name Signatur Y <br /> Rs wv_r <br /> LL 0 18. Trans orter 2 Acknowl ement ofiReceipt of Materials <br /> It I Printed/Typed Nome Sign Fure Month Day Year <br /> to E <br /> a` <br /> l l 19. Discrepancy Indication Space <br /> A <br /> C <br /> I <br /> f 20_ Facility Owner or Operator Certification of receipt of hazardous matt rials covered by Ibis manifest except os noted in Item 19. <br /> Printed/Typed Name Signature Month Day Year <br /> Do NOT WRITE BELOW THIS LINE. <br /> DTSC 8022A(4/97) Yellow: GENERATOR RETAINS <br /> EPA 0700--22 <br />